A number of methods and systems have been developed to look at the costs associated with the service delivered by the physicians. The purpose is to compare physicians or hospitals in terms of those groups which are rendering the most efficient treatment per dollar of cost. This type of analysis is made from the standpoint of the managers of the managed care systems. Thus in U.S. Pat. Nos. 5,724,379, 5,924,073 and 5,953,704, the analysis is oriented toward what should be the cost of the treatment, and for what should a medical provider actually bill. The point of view is not from the point of view of an actual user of Medicare, i.e., one receiving treatment, but from the point of view of the managed care providers. Systems and methods for analyzing medical claim histories and billing patterns have been devised. For example, see U.S. Pat. No. 5,557,514.
Another type of health costs estimation program is that which is from the physician's point of view. For example, a physician might want to decide whether to stay with a fee-for-services or change to a capitation system where the physician is paid an amount for treatment per patient. This type of cost estimating system is, for example, shown in U.S. Pat. No. 5,918,208.
It would be desirable, in addition to having computer based cost analysis programs for health care managers and for physicians, to also have a computer based cost analysis program from the point of view of the user, i.e., the consumer, of the medical services. The insured person, as the one who ultimately pays for the medical services, should be provided with information on which to make choices about which insurance program would be most suitable for him or her or the household.
Today there are many different types of health insurance plans, including HMOs (Health Maintenance Organizations), PPOs (Preferred Provider Organizations), POSs (Point of Service) and FFSs (Fee For Service). Within these categories, there are many different specific plans, each with different benefit designs, costs, and other characteristics. Consumers who can choose between two or more insurance plans thus face a complex choice. Such an individual would do well to have some guidance as to what or how that individual may optimally provide coverage for him- or herself. In the event there is a household, further guidance would be useful for deciding on the household coverage, since most people cover their dependents and themselves in the same insurance plan. Ideally, the user of a medical care guidance system would be provided with comparisons and contrasts of different health plans as to the likely distribution of out-of-pocket costs that an individual or household would incur in each plan in the coming year, and with respect to other plan characteristics. In particular, people choose health insurance for future periods, such as the coming year, yet they do not know how much health care they will use in this future period. For example, a person might be a high user or low user of medical services. There can also be cases where episodes of illness occur. It would be desirable to know what is the likelihood of the illness episodes continuing to happen and what would be the effect on the health costs according to the coverage chosen by the individual. It is highly desirable to have a health cost calculator, which can calculate, over a variety of health or medical situations, what the likely distribution of future medical costs to an individual or to a family household. An additional desirable feature would be to include historical patient information. This would allow prediction, by a statistical comparison of similar individuals and households, of an individual's or household's statistically predicted cost results, from their choice of medical insurance plan, and to provide probabilities of certain types of illnesses and the resulting costs of such, including out of pocket costs.
Moreover, if a consumer of medical services had a good cost calculation of that consumer's likely distribution of future medical costs, that consumer would be in a position to estimate how much money he or she might want to allocate to a flexible spending account (FSA). A consumer might want to have “enough” set aside in the FSA, since that amount would not be taxed. The best “enough” would exactly match the “out-of-pocket” amount spent on medical costs. That way, maximum tax benefit would be obtained and no money would be left “unused” at the end of the year, since that money is not carried over to next year's FSA, but is lost if not spent. The FSA amount decision is made up-front, at the beginning of the year. Consequently, some guidance from a computer-based analysis and prediction program would be useful. The consumer is likely to find such a method for producing optimal estimates of the amount to be aside for the FSA, for the year, to be most desirable.